Tag: junior doctor

Nice to meet you, what brings you here?
I could ask you almost anything,
Rashes, fevers, diarrhoea?
Saw you here and I thought
‘Oh my god, hear that chest,
He should be the next assessed’
The triage nurse is looking stressed.

Bring you in, sit you there,
Talk to Mum about what’s going on.
Assess your throat, look in your ears
And I know you are quite wheezy.
So hey, let’s give some puffs,
I’m hoping ten will be enough,
Grab your spacer, come with me,
I can make your breathing better for a little while.

Cause you’re young and you’re breathless,
You come to A&E.
Run out of inhalers,
No time to see a GP.
Got a long list of visits,
They all say the same.
I’ll give you burst and steroids
You’ll be glad you came.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.

I haven’t said much about Mr. Hunt’s address to the King’s Fund, or the uprising and furore it has caused amongst medical professionals. This will come as a surprise to most of you.

When I say I haven’t said much, I have barely shut up about it to my friends and family, firmly and repeatedly ranting and reiterating all the notions and arguments you will have read the internet over. The reason I have not written about it to date, is that there were people far more qualified and eloquent than myself taking up the battle, and it was enjoyable to sit back and read some excellent, incredibly worded letters and diatribes that were emerging from varying areas of clinical medicine.

The reason I am writing now is because I feel a little as if we are missing the point. It doesn’t matter how many Facebook rants, twitter campaigns, signatures on letters we have, this is not going to change the final outcome.

Jeremy Hunt and David Cameron do not read social media; they have people for that. And right now they definitely aren’t reading it because they are on a nice long, comfortable summer break. It is hugely ironic that Mr. Hunt’s speech criticised doctors for not working hard enough, criticised our union and told it to “get real” about the challenges facing the NHS, whilst he prepared to sun himself for 2 months. No, the jobs aren’t the same, and no, I am not criticising him for his inbuilt holiday. I am just pointing out the incredible timing.

As the media bubble is dying down, and attention is shifting away from the implications of his words, this is the time to take action.

No one in the NHS wants you to be more likely to die on weekends. As a junior doctor who has worked 3 out of the previous 4 weekends, with one still to come, I know how stressful and challenging working weekends can be. I know the devastation of someone dying unnecessarily on your watch. I know the heartache when you leave work at 11pm on a Saturday, a broken human being, and have to return again at 8am the next day. But the issues we face do not stem from inadequate Consultant cover.

Take a typical 400-bed district general hospital; maybe 12 medical wards. During the week, there will be anywhere up to 4 doctors per ward, with consultant or registrar input most days. There will be an entire team of radiographers, radiologists, biochemists, microbiologists, outreach nurses, clinical nurse specialists, not to mention highly trained and experienced ward sisters who know their patients inside out. There will be specialist teams working and receiving referrals, psychiatry, rheumatology, neurology to name but a few. Getting advice about a patient is easy.

Come the weekend, there is one on call radiographer for the entire hospital, potentially 2 biochemists running all the samples sent to the lab, and a team of 4 doctors covering all the wards and running an acute medical take. Usually you will take between 20-30 patients per day, and as such the registrar and one SHO is entirely focused on the take. This leaves an FY1 (with anywhere between zero days and 12 months of experience) and one SHO (a doctor 2-4 years into training) covering all the potentially unwell ward patients.

It is impossible to do a ward round on 400 patients. It is impossible to assess each and every person for signs of deterioration. The only way we know about you is if your day team has handed you over as likely to need review, or if your observations are so horrendous that they trigger a hospital wide emergency call. As I’m sure you can imagine, catching things when they are already an emergency dramatically decreases our chances of turning things around. Now, say someone needs an urgent CT, or urgent blood transfusion, or, god forbid, out of hours surgery or blue light transfer to another hospital. Being the weekend, this takes so much longer, purely due to demand outstripping supply, and the fact that people have to come in from home to perform tests.

You run like idiots from one ward to the next, assessing and managing people who are sometimes on the brink of death. The sense of relief that floods through you on a Monday morning when the normal teams turn up is indescribable. I often compare it to firefighting, only you are fighting so many fires at once you don’t know where to start.

Now, if someone can point out how getting consultants to work longer at weekends will solve this, I’m all ears. The government know that this isn’t the crux of the issue. They are not idiots, and that makes these proposals all the more terrifying. They have identified an issue, which is that the NHS as a whole does not operate the same on a Sunday as it does on a Tuesday. They have created mass hysteria by implying that if you are in hospital over a weekend you will probably die. (As an aside, if you read the literature properly, there is no such obvious link between weekend admission and death, which honestly is a miracle considering how unsafe the working conditions are).

The government has alluded that workers in the NHS don’t want 7 day working. This is a lie. I have lost count of how many times I have said I would happily work twice the number of on calls if it meant twice the number of doctors present. But then they would have to pay us all a fair wage and where would that money come from? To implement 7 day working, you either have to employ more people, or work the current employees harder. There is no money for increased recruitment, let alone the dwindling supply of people actually willing to work in the NHS.

It was the changeover for junior doctors last week. The time for new FY1s, fresh from medical school and enthusiastic about their future careers, to come out into the harsh reality of the NHS. One of these fresh eyed and enthusiastic doctors was working with me on the weekend. He was struggling against a new computer system, no log ons, no patience from nursing staff and discharge coordinators and a demanding consultant. All the while trying to learn how to document properly and order the correct tests. This young doctor worked close to a 12-hour shift (4 hours over his contracted hours) on his birthday. He missed a surprise party thrown by his friends, and finally left the hospital late at night, only to come back bright and early and do it all again the next day. All without a word of complaint and a smile on his face. These are the people keeping the NHS alive in the face of ridiculous proposals and underhand attempts at privatisation. New FY1s, I admire you, and it is for you that we must fight these proposals. Join the BMA, go to meetings, have your voice heard. It might be cynical, but there is a very real possibility that this is a long term plan to privatisation – they raise an issue, try and fail to fix it, and then legitimise the idea that the NHS is no longer viable.

The proposals try to highlight areas of weakness with no legitimate offer of solution, all the while alienating people who willingly give up their time off, their social lives and any semblance of normality and go above and beyond to keep people alive against horrendous odds.

I am not trying to be arrogant, but doctors are the people you want on your side. We are the people who have endured 5 or 6 years of grueling exams, long hours trailing around after consultants in hospitals, and actually celebrated the day when we graduated and were able to work like dogs from 8am to 7pm and beyond for pityingly little compensation and very little thanks. I am not looking for sympathy. We do this job because the rewards are immense. People come into hospital close to death and by our input (and that of many other hospital professionals) go home healthy. We get to see people at their worst, and help them recover. It is a hugely satisfying and rewarding job, and the only reason you still have people doing it is that you never get over the joy of giving someone back their mother/father/sister/child when they thought they had lost them.

And David Cameron and his health secretary have that, and that alone, to thank for doctors and healthcare professionals in general still getting up and going to work in the morning (or middle of the night for that matter).

It is naïve and unrealistic to expect people to work harder, longer, and for less money, which is essentially what the new proposals boil down to. And we are medical professionals, we do not strike, we do not make waves, we accept multiple reforms, none of which have been an improvement on the last, all the while quietly assessing and treating your family, without complaint at 2am, without complaint when we should have left work 3 hours ago, because we know we are privileged to be able to provide this type of care, we know how important it is. But the NHS is running on our goodwill now, and I don’t know how much more we can take.

My current medical placement is on an Endocrine ward. This basically means that as a firm, we should get all the acute diabetes cases; complications including renal disease, ulcers, hypoglycaemia etc. We also get people who have deranged electrolytes such as a low sodium, which in some cases is an indication of an underlying cancer or other disease. If I was in a tertiary centre (big teaching hospital) then I would be seeing exciting, rare endocrine cases such as Cushing’s, Addisonian crises and the like. As it is, in a district general hospital, there are not enough endocrine cases to fill the ward and as such we become the dumping ground for various other cases.

We take the social care cases, the patients who are awaiting placement, the long stayers, people with no discharge destination, the waifs and strays of the hospital. Whilst this feels like it should be a varied job, it is actually the dullest thing in the world. Within a very short space of time these patients are medically stable and they are in need of physiotherapy, OT input and social services for packages of care. Or they are awaiting transfer to a rehabilitation ward, or to another hospital for dialysis, or amputation. A typical ward round for us consists of maybe three or four patients who are medically unwell, and then about 20 medically fit long stayers.

This makes you incredibly lazy as a physician. It is so easy to write “obs stable, afebrile, no new issues” in the notes several times over and then go get a coffee and spend the day surfing the net. It is incredibly easy to miss a hospital acquired infection because you haven’t listened to someone’s lungs for a day or two, or noticed that their catheter is draining more concentrated urine. These guys go off quickly too, they go from months of medical stability to dead in a day or two.

It is a well known fact that increased time in hospital increases your risk of getting an infection and dying. It drives me crazy the amount of time it takes to get these guys out of hospital. I understand that there is a complicated assessment process involved in setting up placements, for example. The patient has to be needs assessed, placed in the right type of care facility, means tested for funding and then the individual home has to be seen and agreed by either the patient or their family. This can take weeks. What worsens this process is the total inability of any professional inside or outside of hospital to communicate with someone else. Social services will require a checklist. They will not communicate which checklist to the nursing staff. The nurses will fill in an inappropriate checklist, fax it off and it will be declined. The decision will not be communicated back to the ward. The doctors will go on the ward round and write “medically fit for discharge, awaiting placement” for weeks on end without knowing where in the process they are. Inappropriate people will be asked about updates – OTs get asked when the placement will be approved even though it is driven by social services, but social services are never on the ward and frustration leads to apportioning blame for delay to the wrong people.

Every time that someone is discharged from hospital with an existing package of care that needs restarting, a section 5 is necessary 48 hours prior to discharge to give the carers time to set up the package again. Everyone knows this is necessary, we know who comes in with a POC and therefore they will certainly need the same or increased POC on discharge, yet inevitably we will get to the morning of departure and it is news to everyone that the section 5 has not been sent. It is apparently impossible for the different teams on the ward to communicate directly with each other. People write their interactions in the notes and other teams don’t read them and then plans are made on incorrect information.

In order to attempt to coordinate all these things, there is a multidisciplinary team meeting on a weekly basis. This is my least favourite activity of the week. At face value, it is an excellent plan. You can get updates from therapy, nurses, discharge teams and doctors and then everyone is on the same page and we can expedite someone’s discharge. In reality, however, most weeks social services don’t turn up, totally negating the point of the meeting for at least half of the patients, or the sister in charge will have out of date information, or the doctors will spend half the meeting discussing someone entirely medical, thereby wasting the time of every other professional in the room. In complete defiance of their job title, the discharge liaison team neither discharge, nor liaise. The social worker never has an up to date ward list and is always at least 3 weeks behind with information. It would make a brilliant sketch show, it would be hilarious if it was exaggerated. As it is, people sit in acute hospital beds costing the NHS £500 per night doing nothing other than eat shit hospital food, go delirious from a hospital acquired infection, or become thoroughly institutionalised because it takes four months to communicate the need for placement, fill in the correct forms and get approval.

I don’t know what the answer is, obviously people should be in a place of safety until they can be appropriately discharged, but should that place be an acute ward in a hospital? Arguably not. In addition, most of the patients have come in with relatively minor complaints such as a UTI or chest infection, and got stuck after recovery due to worsened mobility or inappropriate houses for discharge. This job has definitely highlighted to me the importance of trying everything possible in A&E to get these patients safely out of the door. No one wants to take responsibility for discharging a 92 year old with a UTI in case she goes home and falls. But the other option is a 6 month hospital stay, loss of independence and eventual placement. Obviously, if people are unsafe at home I am not suggesting emergency care physicians chuck them out into the cold at 3AM, however, all most people need is a course of antibiotics, or some IV fluids, or plugging in to community services and they will be fine. Alternatively, we saturate our medical wards with people who have no medical problems, and the doctors become deskilled and lazy, and wonder why they bothered going to medical school in the first place.

So, I am coming to the end of my rotation on O&G. I have exactly 5 shifts left, and that is 5 shifts too many. O&G is essentially A&E but more stressful, and with exclusively hysterical women, babies coming out of teeny tiny holes, and various permutations of bleeding and diseased vaginas. You aren’t really taught much of the theory at medical school, so starting as an SHO on Gynae basically entails feeling like a moron 100% of the time. You are put in a position of authority, asked to examine and assess patients for conditions, most of which you have never even heard of. Dr Google has legitimately been my best friend. It is ludicrous. There is a baseline expectation of competency. You are a SENIOR house officer now; you must know shit. Clearly somewhere in the small print of my contract it told me how to pull knowledge about complex gynaecological presentations out of my ass but I must have missed it.

The pressure is immense. There is a culture of litigation, and as such I would say that 70% of all decisions made in the specialty are about covering the clinician’s behind. Everything has to happen immediately. With no prior training you are expected to juggle women in dangerous pre-term labour, women hosing litres of blood from their uteruses (uteri?), women potentially unstable due to ectopic pregnancies, to distinguish between idiotic and urgent referrals, and do all of this calmly and competently, all the while smiling sweetly at the midwife who was called you to perform an urgent ECG that has been waiting all day because for some reason no one thought it necessary to train midwives how to use the machine, or to print off a discharge summary STAT because the patient absolutely has to go home immediately and midwives don’t have access to the discharge system, or to come and take blood cultures off of someone who has spiked a temperature because instead of re-cannulating them the nurse decided to switch their IV drugs to oral because, they’re the same thing, right?

This leads me to a side rant about the ridiculous lack of competency assessment we have as doctors. I have lost track of the number of times I have been asked to administer a drug because a nurse hasn’t been trained how to, or perform a procedure that a midwife isn’t competent to do, that I myself have had no training in. As doctors, we are expected to be able to just get on and do things. There is very little sympathy for the line “but I don’t know how”. And this is insane. If anyone asked me to produce evidence of competency in giving calcium gluconate, or administering methotrexate, or misoprostol, I would be screwed. Yet I do it frequently.

O&G though, is on a whole different level. There is a guideline for EVERYTHING, but it is never exactly followed. You can assess a patient, make a correct diagnosis, initiate management according to the guideline, and be entirely decimated by a Consultant who has decided, on a whim, that it is not appropriate to give this particular pre-term labourer steroids. And that will be your fault. Acceptance of incompetence, and acceptance of culpability even when it is not your fault are necessary attributes for a successful rotation.Oh, and skin as thick as a rhinoceros.

So, I have compiled a list of possibly helpful, hopefully amusing tips for anyone who may be about to enter an O&G rotation.

Top tips for anyone doing O&G as an SHO:

ALWAYS put in the biggest possible cannula – when these women bleed, they lose their entire circulating volume in minutes. Plus, its so satisfying doing locum shifts in ED, waltzing into resus and placing a grey cannula without batting an eyelid. SKILLS.

Regardless how young, virginal, or skanky a woman is, she is pregnant until the labs have excluded it.

Following on from this, it is an ectopic pregnancy until proven otherwise.

You will be referred at least one woman who is legitimately on her period. A&E will inevitably want you to admit her.

Speculums are things we are ALL taught to do in medical school. The line from ED/UCC/Surgical/Medical Docs of “you’ll only repeat it anyway” is pure laziness, and their impression will be at least as good as yours. Whether you fight this one is personal choice. Frankly, it is irritating but not worth your breath.

“Asian Pain Syndrome” is multiplied exponentially in pregnancy.

Headaches in pregnant people = NIGHTMARE. Even if it is definitely a migraine, you will go home convinced they have a thrombus and are going to die.

Specialty tennis between surgeons and gynae for the women with abdominal pain helps no one. Gynae is seen as the easier option, which can be frustrating, but remember that there is a woman, possibly in agony, probably scared out of her mind, sat somewhere waiting for answers. Accept the patient. Get an USS. Yell at the surgeons later.

Secondarily to the above: Right Iliac Fossa pain in someone who still has their appendix is appendicitis until a surgeon has written that it is not. Regardless of how snarky they are on the phone. No one likes appendicitis because it is a difficult clinical rule-out, but that does not make it an ovarian cyst. Sort your shit out.

“Gynae pathology” is NOT a diagnosis. I have had a lot of fun with this one. If they cannot give you a legitimate differential, then you don’t see the patient.

Run absolutely EVERY decision by someone senior. Even prescribing antibiotics. Even following a guideline. They will look at you like a moron, but you get used to that pretty fast. There is no room for autonomous decisions in O&G, unless you want to be on the receiving end of a court case. Better to look like a moron than be proven one in court.

Remember this rotation is temporary. This is not your life. Soon you can be back doing something you enjoy, unless, of course, you are an O&G trainee, in which case, I salute you, and am getting you a psych evaluation.